Healthcare Provider Details

I. General information

NPI: 1801852447
Provider Name (Legal Business Name): COLLEEN RUTH BRODERICK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2006
Last Update Date: 11/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 S 14TH AVE STE B
SAFFORD AZ
85546-3337
US

IV. Provider business mailing address

8453 S NAVAJO DR
SAFFORD AZ
85546-7753
US

V. Phone/Fax

Practice location:
  • Phone: 480-318-5584
  • Fax:
Mailing address:
  • Phone: 928-792-7842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN000099282
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: